Provider Demographics
NPI:1083847685
Name:OTTENBACHER, HEIDI A (OD)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:A
Last Name:OTTENBACHER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:HEIDI
Other - Middle Name:
Other - Last Name:DEYO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:712 SOUTH CASCADE STREET
Mailing Address - Street 2:
Mailing Address - City:FERGUS FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56537-2813
Mailing Address - Country:US
Mailing Address - Phone:218-736-8000
Mailing Address - Fax:218-736-8757
Practice Address - Street 1:712 SOUTH CASCADE STREET
Practice Address - Street 2:
Practice Address - City:FERGUS FALLS
Practice Address - State:MN
Practice Address - Zip Code:56537-2813
Practice Address - Country:US
Practice Address - Phone:218-736-8000
Practice Address - Fax:218-736-8757
Is Sole Proprietor?:No
Enumeration Date:2009-08-29
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3179152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist